[Date and Time]
1 November 2024, 10:00 AM
Review Since Last Session:
Client reported feeling less anxious overall since the last session, which was held on 25 October 2024. She has been practicing the grounding techniques discussed and has found them helpful in managing her anxiety symptoms.
Current Presentation:
- Client reports feeling anxious when thinking about her upcoming presentation at work.
- Client's self-perceptions and beliefs: Client believes she is not good enough and will fail at her presentation.
- Cognition: Client's specific negative thoughts and their consequences: "I'm going to mess up and everyone will think I'm incompetent." This thought leads to increased heart rate and difficulty breathing.
Mental Status Examination:
- Mood: Anxious
- Affect: Anxious, tearful
- Thoughts: Racing thoughts related to the presentation.
- Insight: Client acknowledges that her anxiety is related to past experiences of public speaking.
Session Content:
- Exploration of the origins of client's negative cognitions: Discussed past experiences of public speaking and how they contribute to current anxiety.
- Discussion of client's past experiences and their impact on current functioning: Explored how past negative experiences have shaped her beliefs about her abilities.
- Strategies discussed for improving social connections and relationships: Discussed the importance of seeking support from friends and family.
Interventions:
- Description of therapeutic techniques used to address client's distress: Utilised grounding techniques and bilateral stimulation.
EMDR:
- (If EMDR was used in the last session, write what has been different for the client since the last session in relation to the target treated. Note any differences the client has now when thinking of the target in the last session)
- EMDR: Name of target if continuing from last session or if starting a new target: Public speaking
- Phase 3:
- Worst part of the target: Image or other sensory information in target: Seeing the audience looking at her.
- NC: Negative cognition identified: "I'm going to fail."
- PC: Positive cognition to replace the negative one: "I am capable and can succeed."
- VoC: Validity of Cognition scale rating "VoC = (number from 1 through to 7) /7": VoC = 6/7
- Emotion: Emotions associated with the target: Anxiety, fear.
- SUDS: Subjective Units of Distress Scale rating "SUDS = (number from 1 through to 10) /10": SUDS = 3/10
- Body: Physical sensations associated with the target: Tightness in chest.
- Complete or Incomplete Target: Complete
- Client's engagement and response to the interventions: Client was actively engaged and reported feeling a decrease in anxiety after the EMDR processing.
- Learnings: what the client reports they have learned after reprocessing with bilateral stimulation during EMDR: Client reports feeling more confident and believes she can handle the presentation.
Risk Assessment and Management:
- Assessment of any potential acute risks to the client: No acute risks identified.
Session Summary:
- Summary of client's progress and topics covered during the session: Reviewed progress, processed a target related to public speaking using EMDR.
- Additional interventions or psychoeducation provided: Provided psychoeducation on anxiety management techniques.
Next Steps:
- Date and time of the next session: 8 November 2024, 10:00 AM
- Planned focus for the next session: Continue working on the presentation target and explore any remaining anxiety.
[Date and Time]
Review Since Last Session:
[Description of how the client has felt and what has happened in relation to the issues discussed in the last session. Include date of last session if information is available.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Current Presentation:
- [Description of client's current feelings and concerns] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Client's self-perceptions and beliefs] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Cognition: Client's specific negative thoughts and their consequences] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Mental Status Examination:
- [Mood: General emotional state] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Affect: Observable expression of emotion] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Thoughts: Content and patterns of thinking] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Insight: Client's understanding of the origin of their thoughts and feelings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Session Content:
- [Exploration of the origins of client's negative cognitions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Discussion of client's past experiences and their impact on current functioning] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Strategies discussed for improving social connections and relationships] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Interventions:
- [Description of therapeutic techniques used to address client's distress] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
EMDR:
- (If EMDR was used in the last session, write what has been different for the client since the last session in relation to the target treated. Note any differences the client has now when thinking of the target in the last session)
- [EMDR: Name of target if continuing from last session or if starting a new target] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Phase 3:] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Worst part of the target: Image or other sensory information in target] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [NC: Negative cognition identified] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [PC: Positive cognition to replace the negative one] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [VoC: Validity of Cognition scale rating "VoC = (number from 1 through to 7) /7"] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Emotion: Emotions associated with the target] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [SUDS: Subjective Units of Distress Scale rating "SUDS = (number from 1 through to 10) /10"] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Body: Physical sensations associated with the target] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Complete or Incomplete Target] (Determine complete if at the end of the session the Body Scan is clear and determine incomplete if still using Bilateral Stimulation just prior to the end of session) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Client's engagement and response to the interventions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Learnings: what the client reports they have learned after reprocessing with bilateral stimulation during EMDR] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Risk Assessment and Management:
- [Assessment of any potential acute risks to the client] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Session Summary:
- [Summary of client's progress and topics covered during the session] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Additional interventions or psychoeducation provided] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Next Steps:
- [Date and time of the next session] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Planned focus for the next session] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
(For each section, only include if explicitly mentioned in transcript or context, else omit section entirely. Never come up with your own patient details, assessment, plan, interventions, evaluation, or next steps—use only the transcript, contextual notes, or clinical note as reference for all information. If any information related to a placeholder has not been explicitly mentioned, do not state that in the output; simply leave the relevant placeholder or section out entirely. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information from the transcript.)